Doctors Disagree on Schiavo's Awareness

Is there any doubt that Terri Schiavo (search) is in a persistent vegetative state (search)?

Yes, argue those fighting to keep her alive, including Gov. Jeb Bush. Doctors have sparred about this before in court, and the most recent ruling upheld the diagnosis.

The issue arose again this week when a neurologist, Dr. William Cheshire of the Mayo Clinic in Jacksonville, Fla., said in a court document that he believed it's more likely that Schiavo is in a "minimally conscious state" than a persistent vegetative one.

In a persistent vegetative state, a person is awake but not aware of oneself or the environment, and making only reflex movements. In a minimally conscious state, a person's behavior shows inconsistent but reproducible signs of consciousness. For example, a patient can occasionally follow simple commands, scratch the nose if it itches, or try to use an object like a comb for its correct use.

Cheshire was not available for an interview, the Mayo Clinic in Jacksonville said in a statement. It said that at the request of the state of Florida he observed Schiavo at her bedside and reviewed her medical history but did not conduct an extensive examination of her.

In his affidavit, Cheshire said Schiavo showed several behaviors "that I believe cast a reasonable doubt on the prior diagnosis" of persistent vegetative state. For example, he said, her face brightens and she smiles in response to the voice of familiar people such as her parents. Her eyes don't track moving objects consistently, but "she does fixate her gaze on colorful objects or human faces for some 15 seconds at a time," he said.

"Although Terri did not demonstrate during our 90-minute visit compelling evidence of verbalization, conscious awareness or volitional behavior, yet the visitor has the distinct sense of the presence of a living human being who seems at some level to be aware of some things around her," Cheshire said in the affidavit.

But the first part of that sentence, in fact, "starts to meet the criteria for vegetative state," said Dr. Gene Sung, director of the neurocritical care and stroke section of the University of Southern California.

Sung, who has not been involved with the case, said of Cheshire that "unfortunately his feelings, and possibly his religious beliefs, are affecting his medical decision." The Center for Bioethics and Human Dignity (search), which notes on its Web site that it was founded by Christian bioethicists, lists Cheshire as its director of biotech ethics.

Sung said the original diagnosis was based on repeated examinations by "very distinguished neurologists" and he called himself as comfortable with that diagnosis as he can be without examining Schiavo himself.

Dr. Roger Albin, a professor of neurology at the University of Michigan who also was not involved in the Schiavo case, agreed. "I don't think there's any reason to doubt the diagnosis... I don't think her evaluation could have been done better."

He also said he's not aware of any evidence that a person could emerge from years in a persistent vegetative state and enter a minimally conscious state, especially in a case like Schiavo's, where blood flow to the brain had been temporarily cut off in 1990.

The diagnosis has been a court matter, both in 2000 and in 2002. In the latter year, a Florida judge agreed with four neurologists that Schiavo was in a persistent vegetative state. Brain scans and examinations were conducted in 2002, but no new neurological evaluation has been ordered since, and the medical record has been closed.

Testimony in those cases included statements from Schiavo's treating physician, Dr. Victor Gambone, who said in 2000 that he agreed with the diagnosis. Schiavo's daily caregivers told him they could not get any response showing an appreciation of her surroundings, he said.

In 2002, Dr. Ronald Cranford, an expert on persistent vegetative states who was brought into the case by Schiavo's husband, testified that key centers of Schiavo's brain probably had no viable neurons left. She was not actually fixing her gaze on her mother, as had been suggested, but rather showing a reflex action seen in patients in a vegetative state.

(Cranford said Thursday he still has no doubt the diagnosis is correct and that Cheshire is "flat-out wrong.")

Two other neurologists also agreed with the diagnosis, including one appointed by the court to examine and evaluate Schiavo.

But doctors representing Schiavo's parents at the 2002 hearing had a different conclusion. Dr. William Hammesfahr, a Florida neurologist, said his examination of Schiavo found she is "definitely aware of her mother" and communicating through following instructions and in looking at people. And a radiologist said a brain scan in 2002 showed more normal appearance than one in 1996 and said there was a "significant probability that she would improve" with certain treatments.

But the court was not given any objective data to support that latter assertion, said Dr. Timothy Quill, director of the Center for Palliative Care and Clinical Ethics of the University of Rochester Medical Center, writing in a commentary published online this week by the New England Journal of Medicine.

Hammesfahr has been a figure of controversy. In 2001, the Florida Department of Health accused him of falsely advertising a neurological treatment and exploiting a patient for financial gain. The treatment is "contrary to current neurological knowledge," the department said. Hammesfahr denied the accusations, and in an interview Thursday he said the probation and fine against him were overturned on appeal.

On Thursday, Dr. Lawrence J. Schneiderman of the University of California, San Diego, a specialist in bioethics of medical futility and end-of-life care, said in an interview, "He's a quack, to put it the politest way I can."

Hammesfahr said he believes Schiavo can be helped by treatment and that numerous other neurologists, some of whom actually examined Schiavo, agreed.

"I'm not the only person who has said she can be rehabilitated," he said. "Are we all quacks?